14 June 2011

Hannah Dahlen: Collaboration or control?

SOME very positive recommendations for women and midwives have come from the National Maternity Services Report.

One essential outcome was the extension of the Medicare Benefits Schedule and the Pharmaceutical Benefits Schedule to eligible midwives in November 2010. This supports the full contribution that midwives can make to maternity care in urban, rural and remote areas and to provide women with real choice.

Despite the positive recommendations, the last minute insertion of the “Determination” — known as the National Health (Collaborative arrangements for midwives) Determination — could hinder Health Minister Nicola Roxon’s good intentions for maternity reform.

US president Barack Obama said: “A good compromise, a good piece of legislation, is like a good sentence; or a good piece of music. Everybody can recognise it. They say, ‘Huh! It works.’ It makes sense.”

The collaborative arrangements for midwives certainly get no “Huh!”. Six months into the new era of maternity care where midwives can provide Medicare rebatable services to women, it is very apparent that few private obstetricians are willing to collaborate with midwives.

Apparently there are currently three in Australia.

Midwives always feared that these arrangements would be used to try to control midwifery practice and impact on women’s childbirth choices, such as the refusal to collaborate if a woman chooses to give birth at home.

Of most concern is the effect of these collaborative arrangements on women living in rural and remote communities where there may be no doctors at all or doctors on short-term contracts with whom midwives must constantly try to negotiate.

There is now a real risk that midwives will not be able to take up the government’s reforms, so they are doomed to fail. Women are not at the heart of these considerations. Rather, medical practitioners, political bastions and hip pockets hold ultimate sway.

I have just returned from the US, where similar requirements for collaborative arrangements that have been in place for the past 15 years are now being successfully overturned. I wonder why we seem unwilling to learn from the mistakes of others.

There were three ramifications of the US collaborative arrangements that led to an untenable situation. First, it was obstetrician specific, so when a supportive obstetrician retired or moved elsewhere, midwives were left high and dry.

Second, insurance companies put pressure on obstetricians and threatened to increase premiums if the doctors took on what the insurers considered an increased liability risk.

Third, when midwifery practices became successful and threatened obstetric incomes, obstetricians withdrew from the collaborative arrangements. In New York last July, just as Australian midwives were forced to accept this untenable piece of legislation, the Midwifery Modernization Act was signed into law, overturning the collaborative arrangement requirement for New York midwives.

Fifteen other US states have overturned similar legislation and other states are now following suit.

Why were these laws put in place in the US in the first place? The answer is political expediency — it got midwifery reforms in and placated the medical profession in order to enable progress. Except it ultimately impeded progress and stifled midwifery as a profession.

US midwives and women were able to demonstrate successfully that this arrangement led to less safe care and was anticompetitive in nature, enabling one competing profession to restrict and dictate the trade of another.

Collaboration is, of course, a very fine and commendable part of safe maternity care, which midwives support wholeheartedly. None of us is an island in health care, and safe care is dependent upon our mutuality.

I was part of the NHMRC Collaborative Guidance Committee that produced a very fine document in 2010 outlining the principles of effective collaboration — without signed agreements. We defined collaboration as “a dynamic process of facilitating communication, trust and pathways that enable health professionals to provide safe, woman-centred care”.

Trust is at the heart of collaboration, along with respect. This cannot be forced into place by a signed agreement with a doctor. Practice and professional regulatory obligations are already in place, such as the Australian College of Midwives consultation and referral guidelines, which guide midwives as to when to consult and refer.

The internationally agreed definition of a midwife says “The midwife is recognised as a responsible and accountable professional …”

So are the collaborative arrangements about collaboration or control?

The success or failure of these reforms inevitably will provide the answer. Sadly, while the professions are at war it is women who will miss out.

Dr Hannah Dahlen is associate professor of midwifery at the University of Western Sydney.

Posted 14 June 2011

Sorry, there are no polls available at the moment.

15 thoughts on “Hannah Dahlen: Collaboration or control?”

Whilst the claim that obstetrician’s practice is hip pocket driven does contain a germ or two of truth (they all drive really expensive cars and some run expensive ‘playmates’.. I am told by industry contacts), the suggestion that they do not care about patient welfare is utterly scurrilous.
If an obstetrician determines that a high risk pregnancy should NOT be managed at home, who is going to force a change?
The midwife? Is she going to take responsibility, as the ‘patient’s pregnancy advocate’ or try and pass the buck ‘You did not encourage her/me enough NOT to do this, Dr…’
Fascinating that (Nurse-Dr) Hannah Dahlen (PhD) does NOT compare the maternal mortality rates in the US and Australia.
Could it be because one is 3 times the other (guess which)?
So much for transparency in research n’writing, eh??

The National Health (Collaborative arrangements for midwives) Determination 2010 (the Determination) is not working.
Doctors who are willing to sign collaboration agreements have been advised by their insurers that they should not do so. Some obstetricians are happy to sign for planned hospital birth with midwife support, but not for homebirth. Midwives who go to hospital with their clients are doing so without any professional recognition, and without any indemnity insurance.
There is no Victorian hospital at which a private midwife can attend her clients as a visiting midwife, despite the government-supported indemnity insurance plan that midwives have purchased. We understand that the Victorian Health Department has given funding to the 3 Centres group to sort out hospital visiting rights/clinical privileges for eligible midwives – a project that may report at the end of this year.
Midwives attending homebirths privately in and around Melbourne have for many years had good collaborative arrangements with the Women’s Hospital and Monash Medical Centre in Clayton. If a woman or baby in the midwife’s care requires transfer to hospital, or referral for specialist assessment in pregnancy, the process is straight-forward, which is in the interest of the wellbeing of mother and baby.
When the woman and midwife have completed the hospital booking-in process, the hospital gives the woman paperwork with the woman’s name on it, clearly marked ‘HOMEBIRTH BACK-UP’. This is evidence of the collaborative arrangement.
Eligible midwives are so far unable to obtain a statement identifying a specific medical practitioner “authorised by the hospital authority to participate in a collaborative arrangement” on behalf of the Women’s or Monash, as required under the Determination.
I believe the solution could be an amendment to the Determination, to recognise and validate this type of collaborative arrangement between the midwife and a hospital that has the capacity to receive women who need transfer from planned home birth at any time in the continuum of care.
ps – There is no option to sign in as a midwife to this site. Perhaps that could be corrected.

@Richard Middleton – When you suggest that a woman might need to be forced to be confined to a model of care because of her risk status which is declared by one sort of professional you might be shocked to know but you are suggesting something quite illegal. Women have the final say about their healthcare and no professional has the right to force them to do anything. You must have consent and have formed a relationship to have this level of trust. What women expect is to have a team of carers who give honest information regarding risks and courses of action and then be respected and free to make a judgement call that best suits her and her baby.

The latest in Ms Dahlen’s growing body of work depicting these as a questions of the rights of women to make “childbirth choices” and the rights of midwives to be emancipated from the “control” of obstetricians. There is also the rarely discussed right of an infant to be born under conditions of optimal safety and with access to the accumulated benefits of hundreds of years of progress in research, technology and practice which have brought about spectacular improvements in perinatal mortality and morbidity. I am distracted from Ms Dahlen’s description of midwives as follows ” the midwife is recognised as a responsible and accountable professional …” by this week’s news that a South Australian midwife Lisa Barrett has failed in her High Court application to prevent the State Coroner from investigating the death of an infant following home birth in 2007 with Ms Barrett as the attending midwife.

The sensible response from Dr Sherwood acknowledges midwives and medical colleagues who have maintained historical collegiate relationships, without all the underwritten legislation now forced upon experienced professionals. For 37 years as a midwife, 25 of those working in the home with women, encompasses a professional practice based on what is best for the woman and her baby at any given time. Harmonious, collegiate relationships with medical colleagues and other professionals have ensured the woman is the focus of appropriate services if any need arises. The woman is the decision-maker with the trusted assistance. The value of needs-based services provided by supportive medical colleagues is the way I choose to continue my midwifery practice.
“I think you have to ask the question, how unhappy was everybody with the previous arrangement?
Very happy.
What was the real need for maternity reform?
None. Except for a simple system that supports women who wish to access Medicare rebates and PBS for midwife services.
“If there was a real need for reform … wouldn’t you have expected a bigger uptake of the reforms?”
Absolutely. Most women continue to employ their midwife without all of the above.
Removing the crippling legislation is the only way to resolve the current impasse. Women have been booking into hospitals, whether birthing inside or outside the system. The simple administrative systems until this legislation have benefited the woman and her professional service providers. Why purport to fix something that isn’t broken? Who has benefited from these demeaning political changes? No-one – just more complicated systems that require more people to problem solve and increased finances to try to make it work.
Back to basics, midwives and doctors working together within their professional capabilities, respecting, trusting and talking to each other.

@DrCoglin highlights that the witch-hunt continues and is supported by the medical profession. When will the State Coroner investigate deaths from severe shoulder dystocia that occur in hospital?
Ms Barrett’s appeal was regarding the coroner’s jurisdiction to investigate a stillbirth based on the existence of Pulseless Electrical Activity (PEA) where there were no signs of life when the ambulance arrived. PEA is not a sign of life and this High Court ruling therefore changes the definition of life (hence the coroner’s jurisdiction) – and then will have wide-reaching ramifications which may affect organ donation and abortion, etc. Not just home births.
I hope the Federal Government will appeal this ridiculous control mechanism (as the US has begun to do).
In the UK 1 in 50 women give birth at home (http://www.nhs.uk/chq/Pages/916.aspx?CategoryID=54&SubCategoryID=135) and a midwife is required to attend birth at home if the woman chooses this location.
Women will continue to choose their own location to birth in Australia, let’s make it as safe as possible and remove the controls (which are not working and were politically imposed in the first place).

The correspondence above suggests some CPD is required.
Re the proposal that an obstetrician’s role is to “force a change”: a competent clinician will be aware that it is not within their scope to force a conscious, competent person to do anything. It is however the midwife’s responsibility to consult and refer according to professional guidelines.
Re higher rates of maternal mortality in the US: this is not necessarily only the consequence of a highly privatised, medicalised health care system, and may be influenced by social factors, including poverty, immigration status, etc.
Re the rights of infants: the law appropriately recognises babies as being part of their mothers until birth, and recognises their mothers as decision-makers for their welfare. Legal experiments to divert from this position have been ethical disasters.
Re alleged bad practice by midwives: this can be expected and can be seen in any profession, including medicine where rare but spectacular examples of bad or criminal practice are well known. It is clearly not appropriate to solve this by making one profession subservient to another.
Both midwifery and obstetric professions have a lot of work to do to meet the challenges of maternity care and become more responsive to women’s needs. I suggest the solution will require moving out of defensive professional comfort zones and listening to what women have to say.

I’ve never quite understood something – aside from perhaps being more available at short notice and in rural areas, what tangible benefits do midwives offer over obstetricians?
What is the incentive for obstetricians to enter into joint contracts with midwives?
As far as I can tell they (compared to an obstetrician) possess obstetric skills, often do not believe in the paradigm of a hospital being the locus of patient care, and in the decision-making process at least sometimes prioritise the layperson patient’s feelings over her birth over more risk-averse or outcome-orientated measures, which obstetricians typically advocate.

I am writing anonymously as I work in a small community. I am a doctor (not an obstetrician) and recently had a baby. I work in a multidisciplinary team which includes a fantastic nurse practitioner so I was happy to have midwives involved in my care. I was in a high risk group. It was fascinating that it was the midwives who put a great deal of pressure on me to proceed in a particular way, ie, no intervention despite indications that it would be safest for interventions to take place. There was no discussion of pros and cons of various decisions. There was an air of disapproval when I had to have an emergency caesarian from a number of midwives who looked after me on the ward (there were two older midwives who were supportive). My obstetrician in contrast did discuss the options with me and respected my choices.
My non-medical husband (who has a doctorate) pointed out that it was like a religious movement. In most areas of medicine there is an acceptance that patients have the right to make an informed decision. It is worrying that this seems to be ignored in the arguments about the relationship between midwives and obstetricians, or rather it is assumed that midwives have more respect for the choices of women. In my experience and that of other women I know this is not true. The women I am referring to do not work in the health sector.
In summary, if the goal is for women’s wishes and autonomy to be respected more midwife autonomy may not be the answer unless there are some changes. I would be very interested in how data is collected in this respect if there are any studies which show the contrary. I know one person’s experience or that of 10 people is not good evidence but it does lead me to some concern.

@Alison Gaffney.. I understand what consent means.
I used my words a bit too loosely.
However, what happens when things go pear shaped after she is allowed free rein of her “expectations” to make perhaps an ill-considered decision for herself and her baby?????
What about the expectations of the obstetrician to be accepted as the person who knows what can go wrong and may be forced into an intolerable situation to save the ‘free spirited’ female and child?
Nobody has the right to demand anybody put themselves in that situation, although many will take it on because they are good people.
What can go wrong??
I’ll tell you…
“Concerned dead eyed board member”: Did you tell her it was dangerous to try and have the baby at home?
“Skewered obstetrician”: Of course I did. I explained at length what could happened to her and the baby and why I thought she should be in hospital. She insisted. As the only obstetrician for 100 kms, I was obliged to help her (in her self-obsessed dangerous) decision, to stay at home.
“Concerned dead eyed board member”: Do you think she understood?
“Skewered obstetrician”: What??? Undestood what?
“Concerned dead eyed board member”: Do you think she understood when you said in her condition a home delivery could be dangerous?
“Skewered obstetrician”: What??? When I said she and the baby could both die?? I would imagine so!!
“Concerned dead eyed board member”: You imagine so.. Do you know?
“Skewered obstetrician”: I repeated the warning several times.
“Concerned dead eyed board member”: But did she understand??
“Skewered obstetrician”: How could she NOT have?
“Concerned dead eyed board member”: But did she understand??
“Skewered obstetrician”: She had to.. What would YOU have done then??
“Concerned dead eyed board member”: I’m not the obstetrican here..
“Skewered obstetrician”: That’s obvious.
Not very nice, especially for the hapless professional try to do their best.
If the obstetrician is going to be involved, his/her opinion HAS to be the overriding opinion.
That or they bail and have no more responsibility what so ever.

Anonymous likens her midwives to those involved in a religious movement. This quote from Dr Dahlen [in a review of a book titled ‘Ten Moons’] is of interest:
“Ten Moons takes us into another realm of thinking – one we hardly visit any longer. It taps into our ancient womanhood, where our bodies, full of rhythms and ebbs and flows were once revered rather than pathologised. It provides the balance to the scientific literature that often misses the point by prioritising statistics over soul. Ten Moons is about our power as women and the possibilities that can come from recognising that power. I have conceived, birthed and buried children under the fullness of the moon. I am linked forever to her pulsing beauty.”
Hannah Dahlen, Midwife, Associate Professor of Midwifery, University of Western Sydney, President Australian College of Midwives

Dr Coglin – are you implying that because Dr Dahlen writes about women’s power or the moon that it in some way makes her less of an expert on birth and maternity services? What I hear is that you feel threatened by women and by nature and hence wish to control it. Sad really as women and nature is what birth is all about. Maybe time for a change of career??

Hannah, well written. However, I am going to lash both groups.
Midwives cannot work alone. I work within my scope of practice as a rural midwife at a supposedly a low-risk birthing hospital. Midwives here are multi-skilled, highly skilled and appreciate the efforts of all members of the team. I am able to also work in emergency as a highly educated nurse with ICU quals. We have a really good relationship built on trust and mutual respect. Birth reformers like Bruce and Hannah have sold us midwives down the tubes. In fact, made it harder for midwives like me who prefer to work in the rural regional Australia because they are now imposing rules on us via our regulatory authority. I now have to demonstrate the % of hours as a nurse and as a midwife, & now as a private midwife TRYing to get eligibilty I don’t fit!! Happy to do PD hours 20+20+20 but the dysfunctional health system, the only employer in town for me, cannot support my practice in both areas. I am now having to chose – nurse or midwife. I am sick of the turf wars with women and midwives stuck in the middle of lobby groups and medicos. I love and want to work as a midwife respectful of women’s choices. I am getting out as I cannot compete or be comfortable in this fit. Time to drive mine trucks – mindless task but pays well ready for retirement in 12 years!

Dahlen and her ilk frequently use the word ‘choice’. Ironically the patient has a much wider choice of options with a good obstetrician than with a midwife. Maybe Australian hospitals could save a hundred million dollars with Hannah’s midwife led birthing. How many children’s lives should we sacrifice for that saving? The fact that these people have demonstrated they are prepared to pursue their ideology to the bitter end, even to the point of sacrificing the lives of their own children, is terrifying. To make matters worse they are now fast-tracking direct entry midwives with no nursing training. Could you seriously prefer a graduate from a 12 month tech course managing your health, to a doctor with 12 years training and experience to attain their qualifications?

Verity, I disagree, while a woman may have a wider choice of options with a good ob. they are all very medically orientated and a woman in this model is cared for by strangers during labour, birth and post-partum with her own chosen doctor (or if at night/weekend someone else on the roster) only dropping by once or twice. We conceive our babies in a moment of love and intimacy yet we are expected to birth in cold, sterile environments exposing ourselves to complete strangers which most of us are not comfortable with at the best of times. How can this be a good way for us to labour and birth when we don’t feel comfortable thus affecting our ability to produce are those helpful birth hormones? Antenatal education provided to women in hospitals is far from adequate and so there is so much fear and mis-information about childbirth in our communities.
By giving women the choice to access continuity of care from a known midwife, women will receive vastly better education about what is normal for childbirth from someone who will actually be caring for them (physically and emotionally) access the whole continuim and who will be with them for most of the labour/birth, if not all, not just ‘dropping in’. All the independent midwives I know already collaborated well with obstetricians/hospitals (it was in their clients’ best interests and their own to do so, because it is good practice) before it became a requirement. Across 4 births I have experienced all types of care options from private ob, public, to indpendent midwifery care, and independent midwifery care was streets ahead of all the other options, with the best physical and emotional outcomes.